Provider Demographics
NPI:1396802260
Name:GLENFLORA
Entity type:Organization
Organization Name:GLENFLORA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:KROPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-739-2821
Mailing Address - Street 1:5701 N FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-2163
Mailing Address - Country:US
Mailing Address - Phone:910-739-2821
Mailing Address - Fax:
Practice Address - Street 1:5701 N FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-2163
Practice Address - Country:US
Practice Address - Phone:910-739-2821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0533311ZA0620X, 314000000X
NC332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405194Medicaid
NC7804192Medicaid
NC3496069Medicaid
NC0456420001Medicare NSC
NC7804192Medicaid